Screening for poverty: identifying an important social determinant of health

“A 41 year-old woman with no documented medical history or family history of disease presents to you complaining of occasional chest pains on exertion. How many would order a stress test to rule-out cardiovascular disease?” asks Dr. Gary Bloch, to a captivated audience of resident physicians currently in training at an academic learning day – a few hands go up. “Now how about if she were a smoker or had high cholesterol?” – several more hands go up. “Now how about if I told you she earned less than $12 000 per year through part-time work, while renting a $600 per month bachelor apartment?” While some more put their hands up, many in the group look at each other, unsure of how this information would impact their diagnostic decision-making.

Dr. Bloch, a Family Physician at Toronto’s St. Michael’s Hospital and a founding member of Healthcare Providers Against Poverty (HPAP), is an advocate for poverty screening. “Just as screening is important for other conditions or risk factors, like smoking, high cholesterol or domestic violence, so too is screening for poverty,” he says. Dr. Bloch and HPAP have been instrumental in producing a primary care intervention tool on poverty that is now endorsed by the Ontario College of Family Physicians and will likely soon be made available to every Family Physician in the province for use in clinical practice.

So why bother with poverty reduction as a health intervention? According to Dr. Bloch, “…because the evidence shows that poverty is a major health condition and the biggest determinant of health, especially for those who live on low incomes.” One only needs to scratch the surface of the growing body of research evidence to see the importance of poverty on health outcomes. Poverty has been shown to account for 24% of person years-of-life lost in Canada, second only to 30% for neoplasms, out of all potential causes of illness. Further, the evidence showing the impact of poverty on the risk of a variety of diseases is quite diverse:

Regardless of this compelling evidence, why is there a need to screen for poverty? “Simply because we don’t know which patients live in poverty and if we don’t ask, we won’t find out,” says Dr. Bloch. With 29% of Toronto families and 20% of Ontario families living in poverty, it is not difficult to comprehend its impact on a significant portion of the population. Although the debate continues about how to exactly define the ‘poverty line’, the body of literature in existence supports the fact that income impacts health across a gradient with health effects becoming more profound at the bottom quintile of incomes. A February 2012 report by the Metcalf Foundation entitled, ‘The Working Poor in the Toronto Region’, highlighted the fact that the number of working people in the Toronto area unable to make ends meet grew by 42% between 2000 and 2005. It is clear that having full-time and year-round employment does not guarantee a poverty-free life and if we do not screen for poverty, we will not be able to identify it as a risk factor. Furthermore, we will not be able to adjust a patient’s health risk (e.g. risk of cardiovascular disease) in diagnostic decision-making, nor connect patients with organizations and resources that will assist them in maximizing their incomes (e.g. disability benefits, welfare supplements, tax credits, old age security, child benefits). Physicians that screen for poverty are in a unique position to suggest and provide opportunities for interventions that can increase income and thereby reduce the effect of poverty on health, while advocating for government policies that can improve income supports and reduce income inequality.

I look forward to the day when screening for poverty as a risk factor for health becomes the standard of practice in every setting, whether it be in the Emergency Room, on the wards of a hospital or in primary care clinics.

Naheed Dosani is a Family Medicine Resident with the Department of Community and Family Medicine at the University of Toronto and is training at St. Michael’s Hospital.

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  1. Ritika Goel

    Thanks for this excellent piece, Naheed! This is so important to discuss especially in our current world of evidence based medicine that constantly focuses on risk factors. Viewing poverty as a risk factor is not often considered. The other concern for providers dealing with marginalized populations is that research is often not appropriately generalizable to populations who are poor with multiple chronic diseases. Risks are higher with this population and we need to be extra vigilant in this scenario.

  2. Carolynn Campbell MSW RSW

    I am going to incorporate this piece into the Social Determinants of Health teaching I do with family practice residents at our Academic Family Health Team. Thank you for it.

  3. Emily Holton

    Excellent piece! There is evidence that Canadians are reluctant to share socioeconomic information with their health care providers ( What can be done to help patients feel more comfortable disclosing their income?

  4. MoHammad Ali Barzegar

    Dr.Bloch’s Observation and suggestion that poverty be considered as a risk factor is an excellent and crucial one which is much more important than the other risk factor like cholesterol …. , which drug companies made billion of dollars of it in selling statins. But poverty not only negatively affect heart, mind, and other organs as rightly was pointed out by Dr. Bloch it is affecting whole life through wiping out all the opportunities for flourishing like education, employment, housing, nutrition and all the other. Social determinants of health. It is just the causes of causes of Ill health.

    For the kind information of the readers, I should mention about my observation in 1970 as a young medical doctor, while I was providing a comprehensive primary health care( preventive & curative) to the rural population of a defined areas. I have realized that inspite of the provision of good primary health care which prevented death of the children from preventable childhood diseases, but children die from malnutrition and newborns die from poor housing due to lack of good heating system in winter time with minus 30 Degree Centigrade. Then as a phsician I have thought that the other vision is required to save the life of the people. With the consultation of the community concerned and the literature I have realized that the needs of the human being as a whole is inter-related, and the specialists devided the needs of the people according their speciality. This division of tasks is so artificial that it is very far from the way of life of the people. That is why internationally lack of community participation is the main reason of the failure of the health and development programs.

    Based on the above mentioned understanding I concluded that the Basic Needs or total development approach which was the topic of the discussion since 1950, and fortunately was initiated by the World Health Organization (WHO) in Thailand, could be a relevant approach. In 1987 I have initiated the Basic Needs program in Somalia as WHO officials , then in Pakistan and lastly in Iran where the program was successful all the three above mentioned countries at experimental scale. But in Pakistan after the visit of the Prime Minister and his cabinet Members, 17 Billion Pakistan Rupees was allocated from the government to the program and was incorporated to the Five Years National Health & Development program of the country in 1998-2003.

    The Basic Needs Program is an integrated socio-economic program to fight poverty and improving quality of life of the people through community involvement and Intersectoral Collaboration. People define it as: A prescription from a qualified Doctor, that not only solve our health problems but solve all of our life problem.

    Fortunately I have arrived Toronto on 16 March and will stay until 9 April 2012 and will be glad to share my experiences with the colleagues who are interested in poverty alleviation and social determinants of health by power Points and a 20 minutes film of the process of the development of the BNs program.Regards. Mohammad Ali Barzegar, MD, MPH.

  5. Lori Kleinsmith

    So pleased to see this topic covered at Healthy Debate, well done, Naheed. I encourage physicians and allied health professionals in all settings to not only incorporate screening and responding, but to gain a deeper understanding of the structural policy forces behind poverty. Lending your voice on local, regional, provincial, and federal poverty/social determinant of health issues is very important.

    In Ontario, The Commission to Review Social Assistance has been seeking input for its final report due in June. Voices and views from health care professionals are very much needed. Federally, we do not have comprehensive strategies with timelines & measured targets to address poverty or housing; these need to be created with all-party support/input and linked with provincial/territorial strategies that exist (not all provinces have one). There are two Bills that have been recently presented that would work towards federal strategies but need widespread support – Bill C-233 and Bill C-400 – write to or talk with your local MPP and MP about these important issues!

  6. Patrick Fafard

    Screening for poverty is an excellent idea as is adjusting treatment to reflect the increased risk.

    That said I am not sure what it means to ask physicians to “provide opportunities for interventions that can increase income”.

    And suggesting that they “advocate for government policies that can improve income supports and reduce income inequality” sounds nice but arguably means little in practice. First, the general attitudes, training, etc. of many physicians is unlikely to lend itself to advocacy. Second, it is far from clear that governments and the voters who support them are more likely to take action direct, redistributive action on poverty because they now know it is linked to ill health. Tackling poverty and inequality is a complex matter that involve much, much more than advocacy by physicians or more generally.

  7. Kevin Bezanson

    Thanks Naheed! Traditionally screening has been narrowly defined as something we should do because early intervention is possible and makes a difference. I think here we are talking much more about our own need for awareness on an individual patient level that will guide how we do and what we do in our therapeutic alliance, knowing it can impact every aspect of care. This is moving past knowing the “right” intervention, to thinking about how we can try to make it work with the realities our patients face. System advocacy will hopefully flow from those shared experiences. Though clearly not sufficient to change the systems, shared understandings are a necessary step.

  8. RationalDecisions

    Poverty is clearly a correlate of health, but is it a “determinant”? To demonstrate that you would have to show that removing the poverty while keeping other variables constant would produce a continuing improvement in health. I cannot recall seeing that being demonstrated.

    It is it tempting to take the post hoc ergo propter hoc line and it is as epistemologically unsound as it always was. It is particularly difficult to assess causal influences when there may be a causal chain among the independent variables. As an example, I was involved in a study which tried to see whether mental ill health was associated with physical ill-health in a random sample of 30,000 UK citizens. There were two results:

    1. The presence or absence of 17 physical conditions (heart failure, heart attack, arthritis, diabetes, etc) was recorded. When cross-tabulated with the presence of absence of mental illness, it appeared that mental illness was a major influence. Those with mental illness were from 1½ to 3½ times more likely to report a physical condition. For no physical condition was the ratio less than 1. It looked like an open and shut case: mental illness was important in the aetiology of physical illness.

    2. However, we noted that there were 8 other independent variables which were also associated with physical illness of various kinds (age, gender, smoking, BMI, living in a deprived area, etc). Which, we asked, were the important ones when the others had been taken into account? The obvious method to partition the variance was logistic regression. We did that for each of the 17 physical conditions and for all 9 potential independent variables. We calculated for each of the 9 independent variables the odds ratio (OR) for each of the 17 dependent variables.

    Had there been a large number of ORs> 1 for, say, mental illness, then we would have been confident that mental illness was an important factor even when all the other factors had been taken into account (i.e. not just on its own with no controls). As it turned out, the only independent variable amongst our 9 for which none of the odds ratios was greater than 1 was mental illness. i.e. the factor which on a univariate analysis had seemed important was in fact, when other factors were taken into account, not only the least important, it was the only one which was unimportant.

    That is not a surprising finding for people who regularly undertake multivariate analysis. At a more practical level it is hardly surprising that the factors which had many more ORs>1 were age, smoking and BMI. Other factors exhibited a variety of behaviours. For gender, for example, for about half the conditions men did worse than women while for the other half the situation was reversed. Old people, smokers, and obese people are more likely to suffer from a variety of physical ailments. If those factors are also more common among the mentally ill, it will look as though the mental illness matters. A multivariate analysis, however, permits us to judge the relative influence of each of these inter-correlated factors.

    In public health if one takes the simplistic view – that poverty is the critical factor – what should one do about it? In a given society poverty is not a phenomenon, it is an epiphenomenon to which many of our independent variables contribute. The fact that is an easy datum to gather does not make it an important one. How do you change someone’s poverty? Perhaps you could do so by giving them money. What is the evidence that such an approach is either an effective or cost-effective policy to change health in the long term? The existence of the continuation of such life-style behaviours, often for generations, argues strongly against such policies.

    By contrast, for smoking, BMI, nutrition, exercise, etc. there is something that we can do and should do. The lesson we learned was “Do not undertake a univariate analysis without also undertaking a multivariate one”.

    • Andrew Holt

      Maybe poverty should be looked at in more general terms with many contributing factors that have multiple causes and effects. For example, is poor health a determinant of poverty? Is poverty purely about the lack of money as implied above, or should we look at poverty in more wholistic psycho-socio-economic-cultural terms? In other words do our statistical modeling techniques lend themselves to properly ‘framing’ poverty due to the highly qualitative nature of poverty? In practical terms, is poverty a cause, an effect or both that emerges from the cumulative and dynamic interaction over time between many qualitative aspects of a persons life – with some of the more obvious being measurable?

  9. Health Council Canada

    This is an incredibly important issue.
    Canadians with the lowest incomes are twice as likely to use health care services as those with the highest incomes. In addition, they are more likely to suffer from chronic conditions like diabetes, arthritis and heart disease, live with a disability, be hospitalized for a variety of health problems, have many mental health issues and to die earlier.
    Screening for poverty as a risk factor is just another way for doctors to gain valuable patient information that may contribute to their health and wellbeing.
    –> In 2010, we published a report on health promotion and moving from a discussion on health care in Canada to a healthier population. Check it out:

  10. Natalia

    To Dr. Mohammad Ali Barzegar,
    Where and when will this presentation take place?

  11. Katheryne Schulz

    I think this is very important and especially when it comes to “mental health.” I actually think we need to start to question the advisability of prescribing toxic psychiatric drugs to people (in general) but specifically and especially to people who are in poor health already due to poverty. What are the effects of these medications on people who are not getting enough calories or proper nutrients or who are missing meals altogether? How is this affecting them psychologically and emotinally? Anyone who has seen any research on this – particularly with regard to low-income women – please respond and let me know.

  12. Mohammad Ali Barzegar

    As. I have mentioned on March 19 in my comment, I am a visitor to Tronto and will stay with my son’s family until 5 April 2012 and I do not have any place to make presentation. If there is an interested institution with enough interested audience who like to see the presentation and a 20 minutes high quality film about the process and health outcome of the poverty reduction , I will be more than pleased to make the presentation. Thanks for showing interest to my comments. Mohammad Ali Barzegar, MD, MPH.

  13. Dr. Mohammad Ali Barzegar

    I agree with your point that we should target the root cause rather than the symptom. In the beginning of our poverty reduction program or Basic Needs Program when I was talking to the community about the empowerment of people and in support of sport and against addiction some hand were raised and they said we are jobless. If you provide us some means of livelihood, we will stop addiction. Then I have thought if the program provide them loan without interest for income generation like live stocks, poultry , farming or small business they may use the loan money for the drugs. therefore I benefited from International Narconon methodology for curing addiction first and then provided them the loan without interest in which both program were a success. As they have promised that they will stop addiction and follow the Narconon program, and they did so. Of course we met our promise too and provided them loan without interest for job creation based on their skill and interest.

    In support of your point that the chemical medicin is not useful for the malnourished. Patients. It should be mentioned here that the Narconon methodology which is based on only Vitamins therapy with high doses, purification with daily 4-5 hours Sauna for one month , physical activity and good nutrition had a high cure rate of above 75%. Even in person addicted to Heroin, Carack and Methadone. While treatment with chemical medicine is a complet failure.

    In another survey we have found that the prevalence of the mental disorder was almost the same in rural and urban areas. But the origins of stress was different. For example in the rural area the origin of stress was the death of the milking cow while in the urban area was the damage of the car due to car accident.I should mention that I am speaking about a country where at the time of the survey no any Insurance policy. Therefor if we do not consider the origins of the stress and only give some medicines , I have doubt about its effect. Thank you. Dr. M.A. Barzegar.

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